Written by Kate Dernocoeur, This Guest Comment appeared in JEMS (The Journal of EMS), February 1990.
Us and them. They're easily recognized. They all have numbers. In fact, they have several numbers, starting with the county call number on down through the address, date of birth, and medical insurance number. These numbers make the people aspect of emergency medicine tolerable so the rest of the job can be enjoyable. After all, where else can you get 20 days off per month and still get paid like a regular job? A few nights ago, one of them called 9-1-1. It was a typically stupid call. Somebody with a headache thinks she needs an ambulance. I was not in the mood."
In almost eight years of reviewing manuscripts for JEMS, I have never felt the profound sense of tragedy that these words evoke—not just for the patient, but for a "profession" that condones such troubling priorities and attitudes. And the saddest part is that people like this author are frighteningly numerous.
There really are people who actually believe patients are secondary to the "true" purpose of the job: to make easy money running a few ambulance calls every third day. Their attitude is that you can actually hide the patients behind the bureaucratic wall of numbers, that people are the footnote to prehospital care, the barely tolerable part of an otherwise reasonable pursuit. They're outraged that someone could be so "stupid" as to call for a headache, thus further spoiling an already-sour mood.
This piece of writing demonstrates a clear misalignment of values and a somewhat cavalier attitude. The author describes this patient as " ... an old, obese woman, her overnight bag in one hand and her insurance card in the other. She had a large urine stain on the front of her dress and remnants of emesis from her chest down to her knees ..." Unpleasant, yes. Repulsive even. But we see that sort of thing all the time. It's part of the job, and if no one mentioned that to you during training, I hope your training program re-examines its curriculum soon. Still, doesn't part of our yearning for professional recognition involve providing emergency care for all people on an equal basis, regardless of race, creed, size or chief complaint? Isn't the stain of prejudice uglier than a washable emesis stain? (See 'Prejudice: Spoiling the Melting Pot Brew," JEMS, April, 1988.)
“There really are people who believe patients are the footnote to prehospital care, the barely tolerable part of an otherwise reasonable pursuit.”
The obvious prejudice in this manuscript bothers me. Yes, we all know that people are treated differently, depending on a variety of factors. If you do not believe that, consider the way we put more effort toward caring for cops and children. There is a gradient of care, and that gradient falls below a minimum baseline of compassion more often than anyone would like to believe.
What about professionalism? The article I reviewed makes professionalism look as foreign as a skid row cockroach on the mayor's lapel. Yet we beg for respect from our EMS teammates, doctors, nurses and each other. That respect will never be earned as long as there are people among us whose behavior, attitudes and values are as unprofessional as those of the individual in this case.
My sense of despair was amplified when I read the following passage from the manuscript. "I put the BP cuff over her long-sleeve sweater and found a pulse at her wrist. After pumping up the cuff to 150, I let it go and waited for the first pulse. It came before the cuff needle made it down to 140, so I knew she wasn't hypovolemic. 'Have you had any alcohol tonight?' 'No.' I wrote down 140/P in the BP box on the field form and 'ETOH on board' under the comments. Since she was obese, I thought I better take another blood pressure to make sure it wasn't high enough to get me in trouble for writing down 140/P."
“The article I reviewed makes professionalism look as foreign as a skid row cockroach on the mayor’s lapel.”
Iatrogenic inaccuracies in documentation (and, thus, in patient interactions) happen a lot. To the calloused and (so he thought) savvy paramedic, this patient was "clearly" a drunk with a headache. Yep, he'd seen it all. What a "stupid" call—until she started to crash, medically. Until he took a second pressure for fear of repercussions from management, for medical/legal reasons, and found a blood pressure greater than 300/P.
The search for excellence cannot be mandated or legislated. We must each seek it within ourselves, and nudge it along in our peers. If we fail to approach each call with a cautious and discerning attitude, with resolve to go the extra mile for every patient, with the dedication that makes patient care the absolute premier priority, aren't we all risking the opportunity for excellence? Isn't patient care what it's all about?
Sadly, apparently not, as long as people have the sort of attitude this manuscript suggests.
The patient in the manuscript presented with equal grips and "a symmetrical face and smile. Although I couldn't smell the inevitable alcohol, at least I knew she wasn't a stroke patient."
In the end, what do we really know? That medicine is an imperfect science. That we are not invincible. That we cannot ever afford to drop our index of suspicion. That no call is stupid. That we must be our own most judgmental critic in search of perfection of our craft, even when we know that is an unattainable goal. That our patients will shock and surprise us constantly.
The patient described here lost consciousness en route to the hospital and died without regaining it. Her CT scan showed an equally bilateral intracranial bleed, thus, the absence of hemispheric signs and symptoms.
Funny how medicine is like that.
Not so funny how some of us decide, over time, that the people are the nuisance part of the job.